CDPH Fines 14 Hospitals $825,000

The California Department of Public Health levied $825,000 worth of penalties against 14 hospitals late last week for serious safety breaches that led to the deaths of five patients. However, the agency had scant details about plans to speed up a painfully slow appeals process that has delayed the collection of about $1.4 million in fines.

The CDPH has issued a total of 221 administrative penalties and levied $8.425 million in fines. It has collected about $6.7 million to date, and granted fine reductions of about $350,000. However, 28 hospitals are appealing penalties, or about one in seven levied, and have yet to pay any fines.

The appeals process includes a hearing in front of a state administrative law judge. CDPH officials confirmed that just a single hearing has taken place. In that 2010 hearing, the agency withdrew a penalty levied against Mad River Community Hospital after a day of testimony. 

Only two more appeals are currently scheduled for hearings. Some hospitals are still contesting penalties levied in 2007, when the CDPH first began issuing them.

“We are looking at out internal processes to handle appeals as effectively as possible,” said Debby Rogers, deputy director of CDPH’s Center for Health Care Quality. Rogers declined to provide specific details.

The penalties meted out last week include:

Patient Death Penalties

• California Hospital Medical Center in Los Angeles received a $75,000 fine and its second administrative penalty for a 2010 incident in which administering CPR to a patient who experienced heart failure while being injected with contrast dye prior to a CT scan was delayed. A nurse declined to call a code blue for the patient. 

• Kaiser Permanente’s hospital in San Francisco received its third penalty and a $100,000 fine for its failure to remove an insulin pump from a patient who had been admitted for high levels of blood sugar. It is believed the pump and other injections of insulin she received led to her death from hypoglycemia.

• Kaiser Permanente’s facility in Los Angeles received its first penalty and a $50,000 fine when staff failed to monitor the vital signs of a patient who had pulled out a femoral catheter, causing her to bleed to death. The incident occurred in 2010.

• Stanford Hospital & Clinics received its first penalty and a $50,000 fine for a patient death caused by a nurse cutting sutures on a tracheostomy tube without prior permission from a physician in order to better clean it. The tube later became disconnected.

• St. Mary’s Medical Center in San Francisco received its first administrative penalty and a $50,000 fine for not properly connecting the tubes of a portable heart-lung machine. The machine disconnected when the paitent was lifted into an ambulance at the facility, leading to his death.

Surgical Error Penalties

• John F. Kennedy Medical Center in Indio received its fifth penalty and a $50,000 fine for a surgical error involving a six-year-old patient. The patient’s tongue underwent a cutting procedure rather than the removal of a lesion as planned. Staff did not perform a required “time out” prior to surgery to ensure they were performing the correct procedure.

• Menlo Park Surgical Hospital received its first penalty and a $50,000 fine when the wrong surgical instrument was used during a pelvic examination, leading to a ruptured bladder.

Retained Object Penalties

• Saint Agnes Medical Center in Fresno received its fourth administrative penalty and a $50,000 fine when a surgical towel was left in a patient’s abdomen, requiring a second surgery to remove it.

• St. Jude Medical Center in Orange County received its fourth penalty and a $100,000 fine for leaving a surgical sponge in their armpit. The sponge was removed some time later in a physician’s office.

• UCI Medical Center received its fourth penalty and a $75,000 fine for leaving a sponge inside a patient’s abdomen. A second surgery was required to remove it.

• Kaiser’s South San Francisco facility received its third penalty and a $75,000 fine for leaving a surgical sponge in a patient who underwent tumor surgery.  The sponge was removed months later after the surgical wound failed to heal properly.

• Saint Francis Memorial Hospital in San Francisco received its first penalty and a $50,000 fine for leaving a surgical sponge in a patient. Two traveling nurses were involved in the surgery, leading to a mix-up in the final sponge count.

• Simi Valley Hospital received its first penalty and a $25,000 fine for leaving a sponge in a patient who underwent a hysterectomy in 2007. The sponge was not discovered until last year.

Other Penalties

• Fountain Valley Regional Medical Center received its third penalty and a $25,000 fine for a 2008 incident when a licensed vocational nurse removed a patient’s gastronomy tube without a physician’s permission. The patient required surgery to replace the tube, and had to take blood thinners for months after discharge.